Registration Form

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Intake Form

Please complete all fields to help us better serve you.

First Name**

Last Name**

Email Address * Please do not use noemail@gmail.com*

Address*

Address, line 2

City*

State*

Zip Code*

County*

Date of Birth*

Preferred Phone*

Secondary Phone

Gender*

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relationship*

Employment Status*

Employer*

Occupation*

Participant Type*

Caregiver Of

Cancer Type*

Treatment received/currently receiving

Name of Physician and/or Oncologist*

Hospital which you or your loved one receive care*

Health Care Coverage*

Ethnicity*

Annual Household Income*

Total number of individuals living in the household*

Number of minors living in the household*

Please type which of these programs you are interested in:

Caregiver Support
Family and Youth Programs
Financial or Legal Counseling
Food Pantry
Individual Counseling
Massage and Reiki
Nutrition
Other - Please explain
Physical Activity and Exercise
Support Groups
Wigs and Beauty
All

Interested Programs*

By submitting this form, you understand and agree that your consent to these services is given in consideration of being permitted to participate in the complementary or alternative health care services provided by Stewart’s Caring Place. You acknowledge that you are a voluntary participant in these activities and assume full and complete responsibility for any injury, loss, or damage which may occur during my participation in these events or while on the premises of Stewart’s Caring Place. You hereby release and hold harmless Stewart’s Caring Place, the complementary or alternative health care provider, and all employees, agents, and directors of Stewart’s Caring Place for any and all claims, causes of action, suits or other proceedings which in any way relate to my participation in the complementary or alternative health care services upon the premises of Stewart’s Caring Place for personal injuries or any other damages sustained.

How did you hear about Stewart's Caring Place*

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